Conflicts of Conscience in Health Care: An Institutional Compromise (Basic Bioethics)

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She has written extensively on conscientious refusals to provide reproductive and end-of-life care, and conflicts between religion and antidiscrimination laws with articles in top law journals, including the Columbia Law Review, Virginia Law Review, and Indiana Law Journal. Please read our policy on commenting.

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Conscience and Health Care Workers

Glenn Cohen, Elizabeth Sepper. Cambridge, England:.

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Cambridge University Press. ISBN For other formats: Link to Publisher's Website. Log in to post comments. By , Medicare regulations, 64 Fed. Current Joint Commission standards require that hospitals adhere to twenty-four guides on ethics implementation found in Sections RI.

Conscientious objection and abortion: rights and duties of public sector physicians

The development of an expectation that health care facilities would offer bioethics consultations was not necessarily based upon empirical evidence of the efficacy of the processes. Such objective data has come more recently in an article by Mark P. Aulisio identified three key areas of competence for ethics committees: skills, knowledge, and character.

Within the skill sets required of ethics committee members are ethical assessment skills, process skills, and interpersonal skills. In the core competencies of knowledge are moral reasoning and ethical theory, bioethical issues and concepts, health care systems knowledge, clinical contexts, knowledge of the applicable health care institution, knowledge of applicable institutional policies, knowledge of the beliefs and perspectives of the patient and staff population, knowledge of relevant codes of ethics for professional conduct and accrediting guidelines, and knowledge of relevant health law.

Key character traits required for effective participation in an ethics committee process include tolerance, humility, patience, compassion, honesty, courage, prudence, and integrity. A facility should not presume that these characteristics are found in the members of its ethics committee but rather should take affirmative steps in training and assessment to ensure that the skill sets are developed and practiced.

I. INTRODUCTION

The American Hospital Association published a Handbook for Hospital Ethics Committees in that identified three primary functions for ethics committees. These functions include educating medical staff, hospital staff, and patients and, in light of the increased emphasis on community benefit to tax exempt organizations since , one would have to add community education as well ; developing institutional policies and guidelines concerning bioethical issues; and consulting and reviewing cases.

The content of educational activities is relatively self-explanatory, but a representative list of policies and guidelines may be helpful for those interested in ethics committee activities. Such a list appears below:. See P. The case review function of ethics committees overlaps a number of organizational roles, including as an expression of organizational ethics, a method of compliance with accreditation standards, and a risk management tool.

Attorneys, 25th Annual Meeting To protect the integrity of the ethics process therefore, it is critical that a clear written charge be developed for the committee, and that the committee members be trained upon and held accountable for adherence to the charge. This adherence to excellence in process and clarity of charge is particularly important in states that have imbued ethics committees with decisional authority.

Law, Religion, and Health in the United States

Alabama, Georgia, and Texas, for example, all grant ethics committees the authority to make end of life decisions for patients who have no identified surrogate decision maker, if certain conditions are met. See Ala. Code Ann. If the committee members are particularly persuasive and the care provider adapts his or her course of treatment, the committee and sponsoring institution should anticipate inclusion as a party in a malpractice lawsuit.

The choice of ethics committee function is therefore a key risk management decision for an institution. This level of review, however, may be least influential in developing either a course of action for an individual patient or an institutional expectation of ethical action.

If the patient representative and physician retain an option about whether to follow the recommendation developed through the committee process, then once again the level of risk to the institution seems relatively low. Where an institution institutes a mandatory review process, however, and also institutes sanctions for a patient or care giver who acts against the recommendation of the committee, then the institution should anticipate that its actions will be subject to challenge in the judicial system.


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Recognizing the risks associated with implementation of a decisional role for ethics committees, some states have provided immunity to ethics committee members and those who rely on or follow their advice. As ethics committee processes are distributed across the country and implemented by a mixture of trained and untrained personnel, however, there is some reason to question whether a grant of immunity provides sufficient prodding to encourage adequate committee member training and care.

As institutions resolve these key issues of role, charge, composition, and training, ethics committees should begin to play an influential role in the ethical life of the organization. With this increased competence and influence, however, it is key that institutions recognize that ethics committees have a different function than an institutional risk management tool. Thus, the governing board and key management should ensure that ethics committees do not inadvertently or intentionally overlap with the functions of peer review committees and quality management committees, which may have separate confidentiality and immunity rights under state law.

Ethics committees should not, for example, intervene in the process of sentinel event identification, investigation, and reporting, but rather must allow the risk management functions associated with these events to be fulfilled within the scope of the sentinel event reporting standards and regulations. Because an ethics committee does not primarily play a risk management function within the institution, risk management personnel should not play a role in the presentation of or deliberation on ethics issues. Counsel to the institution should limit his or her role to the procedural issues associated with the consulting process, and should not be a presenting witness nor provide counsel on the substantive law or the ethical precepts that may apply to a given situation.

A Conversation About Challenging Cases in Clinical Ethics

These roles should be left to outside counsel, an ethics consultant, or a trained member of the committee. Institutional counsel or risk management personnel who play too many roles in the committee process run the risk of becoming a witness if the process goes awry.


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  • Participants in the ethics committee process should be provided a safe setting in which to address problems of information, communication, values, and actual misunderstandings. The salutary effects of physician truth-telling in the context of untoward medical outcomes are becoming well documented in recent years. See T. Gallagher et al. In states in which such laws exist, they should be noted and described to the patient representative.